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Medicare Eye Health Coverage

As people grow older, proper eye care becomes more and more important. In most cases, vision tends to change over time, and the likelihood of developing eye diseases or other types of vision related conditions also increases with age.

Yet, while many people may have enjoyed vision coverage as part of an employee benefits insurance package, most are surprised to discover that Medicare does not cover routine eye exams – nor does it cover most medically necessary eye care or office visits to eye care professionals.

What Type of Coverage Does Medicare Provide for Eye Care?

Medicare does not provide coverage for routine eye examinations (oftentimes referred to as eye refractions) for eyeglasses or for contact lenses. Medicare Part B will provide some amount of coverage for certain preventive eye care, as well as for diagnostic eye examinations. This coverage may include the following:

Annual eye examinations

Glaucoma tests

Testing for macular degeneration

In addition, Medicare Part B will also cover an annual eye examination for diabetic retinopathy by an eye doctor who is legally allowed to perform such tests for Medicare enrollees who have been diagnosed with diabetes.

For this exam, the Medicare enrollee is required to pay 20 percent of the Medicare approved amount for the doctor’s services, as well as the amount of the Medicare Part B deductible. If this exam takes place in a hospital outpatient setting, the enrollee must also pay a copayment.

Medicare may also pay for an enrollee’s routine eye care if he or she is at high risk for glaucoma due to having diabetes or having a family history of glaucoma. An enrollee may be a at high risk of glaucoma if they are Hispanic and age 65 or older, or are African American and age 50 or older. In this case, Medicare will pay for an eye examination by a state authorized eye doctor once every 12 months.

If a Medicare enrollee has a chronic eye condition, Medicare may also cover certain services. For example, Medicare may cover the cost of surgical procedures to help repair the eye’s function such as to remove a cataract and replace the eye’s lens with a man-made intraocular lens.

Medicare may also pay for an enrollee’s contact lenses or eyeglasses in the event that the enrollee has already had cataract surgery during which an intraocular lens was placed into their eye and the customized glasses or contact lenses are now needed following the surgery.

In certain cases, Medicare may even pay for the costs of an enrollee’s eye exam in order to diagnose potential vision issues. For instance, if an individual is having certain problems with his or her vision that are an indication of more serious issues, then Medicare may pay for an eye examination in order to get a better indication of what is wrong – even if it turns out that there is nothing wrong with the individual’s sight.

What Are the Cost Involved with Medicare Eye Coverage?

Generally, for any of the vision care services that are covered by Medicare, you will be required to pay 20 percent of the Medicare approved amount for the doctor’s services. In addition, you will also be required to pay the amount of the Medicare Part B deductible. If you receive your vision care services in a hospital setting, you may also be required to pay a copayment.

How to Obtain Medicare Eye Care Benefits

While eye care is typically not covered through Original Medicare (Medicare Parts A and B), you may be able to obtain eye care coverage through a Medicare Advantage (Medicare Part C) plan. Oftentimes, Medicare Advantage plans will offer coverage that is in addition to the benefits that are offered by Medicare Part A and Part B.

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